Provider Demographics
NPI:1467571562
Name:ESTACIO, DANIEL TORIBIO (DDS)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:TORIBIO
Last Name:ESTACIO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 E CHEVY CHASE DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-2511
Mailing Address - Country:US
Mailing Address - Phone:818-247-3387
Mailing Address - Fax:818-247-2680
Practice Address - Street 1:1140 E CHEVY CHASE DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-2511
Practice Address - Country:US
Practice Address - Phone:818-247-3387
Practice Address - Fax:818-247-2680
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA478861223G0001X
CAOCS 4741223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG-93853-01OtherMEDI-CAL PROVIDER NUMBER
CA25-1918656OtherEIN